A viewer's guide to the Blair House Summit

Some of us will be watching tomorrow's summit because six straight hours of televised health-care reform wonkery sounds like a little slice of of heaven. But we're a rare breed. For everyone else, here's what to watch for:

Is the summit about the problem or the policy? The Republicans have made a strategic decision to counter Barack Obama's ambitious health-care reform package with small, incremental proposals. They believe that voters are fundamentally unsettled by the size of the undertaking, and are more comfortable with a limited, modest approach to the problem. The vulnerability of their approach is that the Republican proposals don't make much of dent in the problem: They don't insure many people nor save much money.

The Democrats are going to try to define success in terms of concrete metrics: Their proposals insure more than 30 million people, and cut hundreds of billions from the deficit. Republicans are going to try to focus on the pieces of Obama's plan that make voters uncomfortable -- its page length, for one thing. If the debate is conducted in terms of the problem and how much the policies will do to solve it, the Democrats have the advantage. If the debate is about isolated provisions of the Democratic proposal, Republicans are controlling the message.

What are Democrats open to including in their bill? Many observers expect Obama to signal a willingness to include at least a couple of Republican policies in his plan. A more aggressive tort reform proposal, a larger role for health savings accounts and an easier path to selling insurance across state lines are the most obvious candidates. That will leave Republicans in the odd position of opposing a bill that includes their core ideas.

Republicans are planning for this, of course, and may well head it off at the pass by proposing a deal that Democrats have to refuse. One possibility here would be demanding that Democrats remove all Medicare reforms from the bill, which would rob the legislation of needed revenue. If your opponent is trying to offer a deal you can't publicly refuse, you need to begin by extending an offer he can't possibly accept.

Is there a reconciliation over reconciliation? The most consequential fight of the day will be over the most boring item on the agenda: The budget reconciliation process. Created in the '70s, the reconciliation is immune to the filibuster, designed to reduce the deficit, and an increasingly common element of legislative life: Ronald Reagan used it for taxes, Bill Clinton used it to reform welfare, George W. Bush ran his tax cuts through it, and Democrats want to finish health care within its warm, majoritarian confines.

Republicans are trying to define this as an abuse of power: "Chicago-style politics," Sen. Judd Gregg called it. Fox News has been calling it the "nuclear option." Democrats have a different term: a majority vote. Republicans will spend much of the summit demanding that Democrats forswear reconciliation as a sign of good faith. Democrats will spend much of the summit refusing to do so unless Republicans agree to give their bill an up-or-down vote.

The likeliest outcome: All of this happens at once, and the two sides talk past each other. In that scenario, the Democrats are probably in good shape, as at the end of the day, the president is the loudest and most popular voice at the table.

"The Democrats are going to try to define success in terms of concrete metrics: Their proposals insure more than 30 million people, and cut hundreds of billions from the deficit."

You know its ironic that I just watched a CNN report on "The Situation Room" that basically said how government estimates are almost always inflated whether it be estimated costs for projects (a B (something plan) was estimated to cost $4.7 Billion and it was $12.7 when it was actually done, the stimulus was estimated to be $787 Billion and is now at $840+ Billion and counting so Ezra you forgot one word in here.

PROPOSED.

Their proposals PROPOSE to insure that many people, their proposals PROPOSE to cut blah blah blah.

Kind of like how medicare was PROPOSED to have cost about $50 BILLION less in 1991 than it actually did.

PS The Obama plan is saving hundreds of billions of dollars, as in plural? The CBO score was just one of those hundred billion. And that's before offering up greater coverage subsidies and a delay in a number of taxes and revenue generating fees (he does have some offset with the new Medicare tax, but not clear how those numbers add up.)

Wisewon -- you're right that the current bills save about $100 billion over the first decade, and it's unclear exactly how that'll change under the President's proposed changes to the revenue pieces. But the vast majority of the savings come in the longer term -- second-decade savings were estimated at $1 trillion, which is many hundreds of billions -- and the various tweaks in Obama's proposal don't do very much to change the picture in the out years.

as you say past performance is no indication of future results but as you well know the "doc fix" is not included so when and if that passes it'll quickly turn this from defecit reducing to defecit increasing. But i'm guessing for some (not necessarily you) that's only an issue when Bush doesn't pay for wars and tax cuts.

Also the stimulus is more expensive because more monies went towards unemployment because as we know the Dems underestimated the depth of the recession and the negative impact of the job market. If it improves quicker than these estimations guess then this will end up looking better. If not, it'll look a whole lot worse. Many economists expect poor job growth (Bernake came out today and admitted he was concerned about it going forward) and it wasn't long ago that several economist warned out loud that many of the jobs that were lost in the last 2-3 years may not ever come back. All those many factors go into play here which is why I simply stated I'd prefer Ezra used the word "proposed" before we ended up with liberals touting that as actual fact and conservatives hold him to it just as Biden was held to his estimation that unemployment wouldn't go above 8%.

I seem to also remember Biden on Meet The Press a couple weeks back saying that we had bottomed out on jobs and from now on out job growth would be the norm. I hope he's right but I'm not so sure and would rather he err on the side of caution.

PS The Obama plan is saving hundreds of billions of dollars, as in plural? The CBO score was just one of those hundred billion. And that's before offering up greater coverage subsidies and a delay in a number of taxes and revenue generating fees (he does have some offset with the new Medicare tax, but not clear how those numbers add up.)

Posted by: wisewon
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And don't forget....those savings are presuming that congress has the political will to make those $500 billion in cuts to Medicare...

History shows us they haven't been able to do it in the past.

And we haven't even talked about the doc fix....another $250 billion....

visionbrkr: fair points, but given the lag between passage and when the subsidies kick in, the economic picture over the next 18 months shouldn't make much difference to the 10-year cost of the bill. If we're not out of recession in 2014, the fact that health reform saves $70 billion vs. $100 billion over the decade is really the least of our problems.

On the doc fix, yeah, everyone knows that'll happen, if not in this vehicle than in some other way, but to my mind that's not really a question of saving or spending -- it's a question of acknowledging that our deficit is actually $250 billion larger than the official estimates. In a perfect world we'd get rid of the accounting distortion in a way that puts us on track to minimize the budgetary impact, but given the overall economic condition of the country, I think putting a long-term fix off for a couple of years isn't necessarily unreasonable, though not exactly a profile in courage.

agreed with all your points and then I'll make one more and its one that I think will, with escalating costs prove even more valid towards making this reform a farce. The individual mandate has now been weakened TWICE due to politics. How's the old sayin go, "California here we come". The death spiral will make WellPoint look like a charitable organization and Ezra's forgotten that little fact.

"as you well know the "doc fix" is not included so when and if that passes it'll quickly turn this from defecit reducing to defecit increasing"

The "doc fix" is a completely separate issue from the democratic health bill! The doc fix will need to be passed anyway (or not), and so any offset savings from health reform will only decrease the rate of growth of the deficit if it is passed.

Additionally the health bill includes research funding and a Medicare commission and that can make reccomendatioins such a bundling or capitation, and has (hopefully) the cadilac tax... No matter which way you cut it we are 1000% better off if democrats pass the bill than if they dont.

The summit starts at 10 AM Eastern, and will be on CSPAN at minimum -- probably portions of it will be on the cable networks, though I doubt they'll run the whole thing!

Boosterprez: the savings are in the same bill as the subsidies. If Congress wants to pass reform, it has to vote for the $500 billion in Medicare savings. Of course they can always try to revisit them later, as they do with the doc fix/SGR, but if you look at the track record, it's pretty clear that SGR is an outlier because it's badly designed policy, and that in fact Congress has regularly stuck to its guns when it comes to cutting Medicare costs:

visionbrkr: You do need a strong individual mandate, but I think there's good evidence what's in the Senate bill will work. The penalties are comparable to or larger than those adopted in MA, where the mandate has been quite successful in getting almost everybody into the system. And of course MA's health care costs are among the highest in the nation, so if anything you'd expect even higher uptake.

It's not just a matter of penalties -- MA did a very good job of outreach and providing on-ramps to coverage, and none of that should be taken for granted -- but I don't see much of a reason to think that the Senate mandate will fail.

lazza11: yes, exactly. And the latest versions of the payment board have actually expanded it so it can make recommendations across most public programs, not just Medicare, as well as creating model policies to help private insurers lower costs and get around collective action problems (though there's nothing binding on the private insurers).

NO to higher tax bills,
NO to losing their jobs because companies can’t afford to pay the higher insurance costs, NO to mandates to buy insurance they don't want or pay a fine imposed on them by the dreaded IRS
NO to stripping the Medicare budget to help pay for another TRILLION dollar entitlement program when Medicare is already going bankrupt
NO to higher deficits
NO to bribes to buy votes that according to Fox News Judge Napolitano is illegal and (once the GOP gains power) will be investigated and prosecuted
NO to Obamacare!!!

The Summit will just highlight that the Republicans have more common sense than the Ds…Their bill is simply indefensible. The majority of people are against this bill because it will (1) drive up costs while (2) cutting a half trillion in health care for the elderly (3) Raise Taxes during tough economic times and (4) give sweetheart deals to Democratic special interests like Big Labor, Big Trial Lawyers and Big Pharma. If you really want to cut costs, then why don't you adopt the GOP plans regarding Tort Reform that the CBO says will save over 52 billion per year. Then you can move on to another GOP idea such as ending state mandates so a person in New Jersey doesn't have to pay 3 times as much for the same policy as a man in New Jersey.

There is no GOP malpractice reform proposal that saves $52 billion per year. CBO has scored a very aggressive package including caps on noneconomic and punitive damages, significant shortening of the statute of limitations, and eliminating rules that help injured plaintiffs recover when some of the parties at fault are judgment-proof.
These are policies that go beyond just weeding out "junk lawsuits" and would mean that some patients injured by negligent medical errors would not be fully compensated for the harm they wrongfully suffered -- it's about as aggressive an approach as imaginable.

CBO found that this approach would reduce the costs of defensive medicine by $6 billion a year, and reduce compensation to injured patients who had proven that their doctors mistreated them by $4 billion a year. That means that there's a $4 billion cost shift that's a one-to-one wealth transfer from injured patients to doctors and hospitals, and $2 billion in net reduced costs (about .1% of annual health care costs).

http://cbo.gov/ftpdocs/106xx/doc10641/10-09-Tort_Reform.pdf

Alternative approaches like insulating providers from liability if they use evidence-based treatment protocols, and encouraging them to talk more with injured patients and give them more information about medical errors, appear to have some promise for decreasing lawsuits in a much more consumer-friendly fashion, but to my knowledge the potential savings associated with them are still fairly speculative.

Theory is following practice here, inasmuch as I live in a state (CA) that has instituted similar policies and found basically no impact on costs.

The evidence is overwhelming that health care costs too much because we use too much of it, and we use the wrong treatments. Getting distracted by the red herring of medmal is a guaranteed way to avoid fixing the real problems that bedevil us.

I have placed bets with people on how long it will be until the Prez first puts out his arm, palm forward in the school bus patrol "halt" gesture he has and says "now wait a minute, wait just a minute, wait a minute, just a minute..." Meaning shut up! There can be no debate with this man because he pulls rank. He shuts people up. He's the president so everyone else has to stand down. Some "summit." Ridiculous. But I say no more than 45 minutes elapse before we get the crossing guard halt signal, and the "now wait a minute, just a minute..."

what I can't get past is that Dems all along have said that the goal must be to control costs. If that's the goal and President Obama believes he can reach that goal then why does he need to raise the excise tax threshold???

Back to the mandate. I do believe the Senate was better than the President's but its quickly getting watered down from the more positive SFC version, to the Senate bill to this. I don't trust the intestinal fortitude of legislators to "do the right thing" when it comes to the mandate.

Also, as far as the medicare commissions go I feel the same way. I don't trust Congressmen and women who are always looking towards their next election to make the critical decisions necessary to reform the system. When you reform the system, when you TRULY reduce cost, someone loses. Doctors, pharma, insurers, patients. Someone has to lose. There is no magic money tree. Short of reducing the NEED for care someone has to take less and no one here is taking less. Maybe insurers a little but their premiums are being largely subsidized. Pharma, no. Doctors not yet and the doc fix should resolve that issue. The only ones to lose seem to be AGAIN the taxpayer.

You said, " the president is the loudest and most popular voice at the table."

No, I'd say the American people have had the loudest say at the table on this issue.
If it weren't for the American people rising up against this government takeover monstrosity, Obama wouldn't be holding his little Kabuki theatre tomorrow.

Dems have majority power in Washington and they are still having to shove this crappy plan down the throats of the American people.

Latest polls say over 70% of Americans want this bill and its variations scrapped.

In the end, don't ever forget Obama works for the people, no matter how much he would like to believe it is the opposite. Same for Pelosi and Reid.

Ummm. I assume you are referring to the "deficit reduction" that is achieved through collecting new taxes for 10 years and paying out benefits for 6 years plus $500 billion in Medicare cuts? That dog just ain't gonna hunt.

Hey Ezra,
I know you were soliciting ideas for a better term to deploy when talking about reconciliation. How about a "constitutional vote"? This sounds better to me than a majority vote or up-or-down vote because it works to remind everyone that the Constitution only requires a majority vote for legislation, and that filibusters and clotures and everything else are artifacts of the Senate rules not Constitutional government. Somebody may have already suggested this...I didn't investigate the comments after your post on the subject. Just a thought.

visionbrkr -- I 100% agree on the politics of lowering costs being very very difficult. But that's actually what the payment commission is taking aim at. It's fundamentally a different sort of animal from the blue-ribbon type commissions that never actually get anything done; it's more like the Base Closing commission from a few years back. In years when the growth rate in Medicare is too high (relative to a defined baseline that's pretty strong), it makes a set of recommendations to lower costs that can't be filibustered or procedurally sidetracked, that can only be changed or amended if you get the same savings as in the initial proposal, and that get an up or down vote. That's a pretty strong shift in the balance of power -- obviously advocates for cost-lowering policies will have to continue to organize around the recommendations and push past the interests that want to keep costs high, but it definitely makes things significantly easier.

It's also been watered down, then strengthened, then watered down, then strengthened through the process, but it's still one of the things that has some ability to change the political playing field which right now is not friendly to attempts to lower costs.

bgmma50: you appear to be mislead on how the bill's revenue provisions work. As passed, the Senate bill begins subsidies in 2014. The excise tax would have begun to be collected in 2013, but that's been delayed in the President's proposal; the drug and device fees do begin to be paid immediately (though IIRC they've also been delayed and mitigated somewhat). If you look at the score, it's pretty clear that both the real revenue and the real spending start kicking in at the same time, with a little bit of revenue boot-strapping but not very much (on the order of 1%). The info's on pages 5 and 6 of this link:

Judd Gregg might like to see himself on tape explaining how reconcilation is a "normal Senate procedure." Rachel showed it last night. I never knew he was a Chicago-style gang politician until I saw him raging because they couldn't get enough votes to open ANWAR to drilling thru reconciliation. Caught on tape, Judd.
Hypocrit!

"The public is clearly opposed to the Democrats’ health care bills. Americans want to scrap these big-government plans and start over with common-sense, incremental reform." -Sarah Palin
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